Talk me up...or down

To all who have been through the match, I need some realism before I put my family through unnecessary pain (or on the flip side decide to put them through worthwhile pain). I'm an MS-3 from a program with no urology clerkship in a somewhat unusual situation. I took paternity leave when I had my second child (before I decided on urology) and will have to make up my family med rotation for the first 2 months of 4th year.

Given the early timeline, this means in practice I'll be able to fit in only 1 away rotation before interviews begin. My plan was to go ahead and apply for 1 additional away later in the year after all is said and done both for practical experience and to make sure that I'm sending a signal of interest despite my circumstances. Will I have a significant problem only doing 1 away before applications are due? And what if I need to turn in one strong letter from a non-urologist? I do have an advisor who is a somewhat connected retired urologist willing to write 1 good letter and make some calls as well. I would be fine with matching a third tier program given my situation but I would also prefer not to be among the unmatched! Having two kids (and a wife who's also a third year), I'm trying not to put my family through the pain of the aways if my chances are really not too great. Other relevant details: 233 on Step 1; a significant resume before med school with lots of interesting international/policy work for real organizations but no research to speak of. All thoughts and advice welcome including innovative ideas on how to thread this needle.

Step 1 isn't so bad. Average was supposedly in the mid 240's this past year but no one really knows for sure. Either way, applicants from my school said the match was brutal. If you're serious about urology you need to consider taking a year off and do this correctly.. especially since you don't have a home program that will take you if you don't get enough interviews. ~25% of people matched at their home programs this past cycle. Most people are doing 2-3 away rotations on top of their home SubI. You need 3-4 strong chairman's letters. This is just the letters part. Whats your research like? Most people are applying with at least 6 entries in their research portion of ERAS. I'd really suggest you take a year off and get research done somewhere else other than your home school so you can get letters and have a good chance of matching there. Goodluck.

It's not impossible, but it's not ideal. There is already an uphill battle coming from a school that doesn't have a home department. Urologists like letters from people they know and you aren't really maximizing your chances of getting these letters given your scheduling difficulties (not your fault, I understand). Usually sub-par step 1 and/or lack of research isn't fatal alone, but in combination and without a strong home department this is a big ask. People might be interested in your policy work once you get in the door, but a lot of the conventional stuff acts as the screen to get you to interviews.

All of this is to say that if urology is your dream, you should go for it, but in one of two ways. Either take a research year and just collaborate with some big people at another institution and crank out work or apply to urology with a backup specialty as well. If going unmatched is unacceptable, these are going to be your best options. Don't give up on urology though if it's what you want to do--you'll be working in your specialty for decades so an extra year, even if you have kids to support, is worth it to do what you like.

Ok so I don't want to alarm you but there are some major issues you will need to overcome.

1) The fact that you are unable to do urology rotations the first 2 months of MS4 (I'm assuming July and August) is very bad, because the letters of recommendation (LORs) you would get from those rotations are critical in getting interview offers. The rotation you do in September will only benefit you with that particular program, since the LOR from that program would not be submitted in time for ERAS deadline.

2) Unless you had something like a significant year-long research experience with a non-urologist, every LOR should come from an active, academic urologist. A retired urologist is useless as a LOR (unless he was a very big name in academic urology) since he won't be able to say anything about your clinical skills or knowledge base in relation to other students. By the way, urology programs require 3 - 4 LORs, but practically every applicant makes sure to submit 4 LORs, all from urologists (or research mentors).

3) 233 on Step 1 is below average for the urology applicant pool. You need to crush Step 2 CK and have the score back in time for application submission.

4) No one is going to care about international/policy work background, especially if all of it happened before medical school. You need to have some research experience in urology (clinical/translational/basic) to beef up your CV, and actually demonstrate with action (not words) that you are interested in urology.

I think when all is said and done, you really need a research year between MS3 and MS4. That will improve your CV with urology research, as well provide you with a (hopefully very good) LOR from your research mentor. By ending your research year at the end of June (so really 10 total months of research) you will be able to do 2 - 3 urology rotations as a MS4 and obtain all required LORs before applications are due.